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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200938
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:30:56 PM


Document Has Been Signed on 03/08/2024 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:SILVERADO SENIOR LIVING-BERKELEYFACILITY NUMBER:
019200938
ADMINISTRATOR:EMORUWA, JEFFREY OFACILITY TYPE:
740
ADDRESS:2235 SACRAMENTO STREETTELEPHONE:
(949) 240-7200
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY:90CENSUS: 79DATE:
03/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sara Vafaeeenia, Director of Health ServicesTIME COMPLETED:
01:00 PM
NARRATIVE
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On 03/08/2024 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/26/2024. LPA met with Director of Health Services(DHS) and explained the purpose of the visit.

The incident report received stated that Resident (R1) eloped from the south side exit door of the facility at 7:17PM on 02/24/24. Staff (DHS) reviewed security footage and confirmed R1 eloped at 7:17PM that night. Staff reset the exit door alarm at 7:19PM and did not immediately look for missing R1. Records review of R1's physician's report dated 06/24/22 indicated that R1 is not able to leave the facility unassisted. Incident report dated 02/26/24 showed that R1 was noted missing by staff at 7:30PM when caregiver went to look for R1 to assist him to bed. At 7:43PM, R1 was reportedly found by a concerned citizen who called the facility with the location of R1. Staff returned R1 safely back to the facility at 8PM on 02/24/24. DHS stated staff notified her of R1's elopement incident at 8:17PM on 02/24/24. LPA obtained a copy of the staff roster, resident roster, resident's (R1) physician's report and progress notes for the month of February 2024 during the visit.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report was provided to DHS.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/08/2024 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SILVERADO SENIOR LIVING-BERKELEY
FACILITY NUMBER: 019200938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
87705

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In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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By POC due date, DHS agreed to conduct in-service staff retraining on safety measures to timely implement proper resident elopement procedures
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This requirement was not met as evidenced by the lack of timely response by staff to actively find resident (R1) when he eloped from the facility’s south side exit security door on 02/24/24.
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in compliance with Title 22 Section 87705 Care of Persons with Dementia and submit to CCL completed staff retraining certifications as proof of correction.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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